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Title: |
| Antiemetics Quantity Limit Override Criteria |
Program Objectives: |
| The intent of the antiemetics quantity limit is to encourage appropriate prescribing quantities as recommended by Food and Drug Administration (FDA) approved product labeling. Oral and transdermal dosage forms of both brand and generic products are included. Injectable dosage forms are not included in the program. Requests for injectable dosage forms will be forwarded to the health plan. The intent of the post-quantity limit criteria for the antiemetics is to allow for review of requests for quantities exceeding the determined limit. Requests for larger quantities may be approved when the prescriber provides evidence indicating extended chemotherapy or radiation treatment, delayed emesis due to highly emetogenic chemotherapy, or hyperemesis gravidarum. |
Recommended Quantity Limits: |
|
| Medication |
Quantity Allowed per 30 days |
| Aloxi® (palonosetron) |
5 tablets |
| Anzemet® (dolasetron) |
10 tablets |
| Emend® (aprepitant) |
6 capsules |
| Emend® Therapy Pack (aprepitant) |
2 packs |
| Kytril® (granisetron)* |
12 tablets |
| Kytril® Oral Solution (granisetron)* |
60 mL |
| Sancuso® (granisetron) |
1 transdermal patch |
| Zofran® (ondansetron)* |
18 tablets |
| Zofran® ODT (ondansetron)* |
18 tablets |
| Zofran® Oral Solution (ondansetron)* |
100 mL | *available as a generic and included in quantity limit program
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Effective Date: |
| 10/08 for Oklahoma |
Prior Authorization Criteria For Approval: |
Aloxi®, Anzemet®, Emend®, Kytril®/granisetron, Sancuso®, Zofran®/ondansetron
Initial and Renewal Evaluation
1. Is the quantity requested greater than the set limit?
If yes, continue to 2.
If no, review is not applicable. Claim will adjudicate.
2. Has the prescriber submitted documentation in support of one of the following:
a. Cancer chemotherapy or radiation therapy related nausea and vomiting in situations where the patient will be receiving extended treatment
b. Delayed emesis in highly emetogenic chemotherapy
c. Hyperemesis gravidarum
If yes, approve for 12 months.
If no, continue to 3.
3. Has the prescriber submitted documentation in support of the requested therapeutic use and quantity for the requested medication?
If yes, pharmacist must review and may approve for 12 months based on information provided.
If no, deny. |
| CPT® only copyright 2003 American Medical Association. All Rights Reserved. | |
